Recent figures show that 151.7 million nonelderly Americans who had private insurance received that insurance from their employers (out of 167.5 million with private insurance). Employers who contract with health plans on behalf of their employees influence the health of their employees and, in turn, the nature and quality of the healthcare system in the United States. Despite the magnitude of their influence, they have been relatively free from both government and ethical guidance with respect to the specific substantive benefits they offer their employees. Employers have enormous discretion with respect to what substantive benefits they include in employer health plans because they are governed by the Employment Retirement Security Act (ERISA). But the decisions that employers make when they choose benefits for their employees are just as much rationing decisions in need of bioethical analysis as are the rationing decisions that are made at the bedside by patients, physicians, and their families. Moreover, even strong discretion, of the kind employers have, is subject to ethical standards.